Present-on-admission indicator (POA)

POA refers to conditions that are present at the time an order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department (ED), observation, and outpatient surgery, are considered
POA. Coders should report a POA indicator for a principal diagnosis, as well as any secondary diagnoses or E codes. POA ties in with MS-DRGs because even though a condition may be classifi ed as a CC or MCC, that do not mean that it will affect the MS-DRG assignment. This is because as of October 1, 2008, hospitals will not receive additional payments for cases in which one of eight conditions develops but was not POA. CMS will reimburse these cases as though the secondary diagnoses were not clinically present.

Consider the following example:
A patient was admitted with acute atrial fibrillation and developed a decubitus ulcer during the hospitalization, which is identified by a POA of “N.”
The DRG assignment would be MS-DRG 309; however, because the decubitus ulcer was not POA, CMS will calculate this case as though it were not present. This would result in MS-DRG 310.

The UB-04 includes an indicator field specifically designed for POA assignment. Coders have to determine whether a condition was POA when the patient was admitted to the hospital or whether it developed during the hospital stay. Once coders find this information, they can report one of the following indicators in the proper field:

• Y/Yes: Present at the time of inpatient admission
• N/No: Not present at the time of inpatient admission
• U/Unknown: The documentation is insufficient to
determine if the condition was present at the time of
inpatient admission
• W/Clinically Undetermined: The provider is unable to
clinically determine whether the condition was present
at the time of inpatient admission

Coders can use several documents to decipher POA
information:
• ED notes:
• History and physical (H&P)
• Progress notes
• Consults
• Admission forms
• Laboratory and x-ray reports
Coders should remember that admission forms, lab reports, and x-ray reports don’t support a POA indicator. To assign POA, coders must rely on a treating physician’s
documentation.